Consent Form www.frozenshoulder.com Ltd

Before you start treatment with a practitioner we would ask you to read and sign our consent form. The following is an indication only, each case varies:

• If you are in early phase I (freezing) you may require between 8 and 15 sessions (depending on severity) - it may take up to 5 sessions to significantly reduce the pain; • If you are in phase II (frozen) you may require between 5 and 9 sessions (depending on severity) - it may take up to 3 sessions to significantly reduce the pain; • If you are in phase III (thawing) you may require between 4 and 7 sessions (depending on severity; • If you are diabetic, treatment can take longer; • If your frozen shoulder has come on following a major trauma or surgery it may take longer • Treatment can be painful, but is usually no worse than the pain of frozen shoulder

Our commitment to you:

• We will do our utmost to help you through this condition using a unique hands-on treatment method 'The Niel-Asher Technique® • All practitioners in our clinics are registered with official state governing bodies; • You should see a tangible (measurable) improvement after each treatment session; • In the unlikely event that you report no improvements after 5 sessions your case will should be reviewed by another practitioner; • You are free to pull out of treatment at any time; • If you are not happy or have a complaint about your treatment, we operate a confidential and impartial complaints procedure.

I have read and agree to the above consent form: Print name of Patient: _______________________________________________________ SIGN: _______________________________________________________ Date of Consultation: ________________________ Name of Practitioner: _______________________________________________________

Please complete and return to:

Frozenshoulder.com Ltd 108 Swains Lane, Corner 12 South Grove, Highgate, London N6 6BS, United Kingdom